1. ORDER IT RIGHT, WRITE IT RIGHT Module 4 Critical Communication:
Reporting Critical Lab Values
NPSG #2: Improving Effectiveness of Communication

2. Timeframe for Telephone Orders
Telephone orders MUST be reviewed and signed by a physician within 48 hours

3. Obtaining Telephone Orders
Licensed nurses, CPs, RDs, PTs may accept and implement medical orders
Pharmacists may accept verbal orders DIRECTLY from a physician

4. Requirements of an ORDER
Signature of the transcribing person
Date and time of order
Type of order, be it Verbal or Telephone

5. Read IT Back ALWAYS Read It BACK
After the order is transcribed, it must be read back to the physician

6. Receiving Critical Lab Result
Always do the following after receiving a critical lab result:
Write it Down
Read it Back
Document
Date and Time

7. Unapproved Abbreviation
QD, QOD
U or IU
MS, MSO4 or MgSO4
Trailing Zero or
Lack of Leading Zero

8. Handoff Communication
Situation
Background
Assessment
Recommendation

9. Definition of Report
Report is providing information pertaining to the patients. It is generally given by the nurse in charge of the patient to the next provider of care. It provides the opportunity to provide information regarding the condition of each patient and any changes that have occurred during the shift.

10. Characteristics of a Report
Reporting is a transfer and acceptance of patient care responsibility achieved through effective communication.
Reporting is an interactive communication, allowing the opportunity for questioning between the giver and receiver of patient/client/resident information.
Reporting includes up to date information regarding the patient care, treatment and service, condition and any recent or anticipated changes.

11. Characteristics of a Report
Reporting requires process for verification of the received information including repeat-back or read-back as appropriate.
The receiver of the report has the opportunity to review relevant patient historical data, which includes previous care, treatment, or services.
Reporting is required for all patients.
REPORTING is HANDING-OFF
your patient to the next
provider of care